A Thousand Operations for Ulcer Disease

Abstract

A retrospective study of 1068 patients who had operations for peptic ulcer disease in the 12-year period from January 1, 1974, to January 1, 1986, permits these conclusions: The number of patients admitted to the Massachusetts General Hospital (MGH) has declined steadily in the years of this study--1974-1986. The average number of patients admitted with a diagnosis of peptic ulcer disease in precimetidine years--1974, 1975, and 1976--and in recent years--1982, 1983, and 1984--shows a decline of 39.3% in admissions. In the same periods, the average number of operations per year has declined from 92 in precimetidine years to an average of 71 (16.5%) recently. The decline has been greatest in patients operated on electively for duodenal ulcer. Operations for massive hemorrhage and acute perforations and the number of deaths have remained nearly constant. The overall mortality rate was 10.3%. The mortality following elective operations for pain was 0.5%; for urgent operations, including those for obstruction, 4.5%, and for bleeding other than massive, 7.5%; and for emergency operations, including those for acute perforation, 20.9%, and for massive hemorrhage, 22.1%. The main causes of death were organ failure (most commonly of the lungs) and sepsis. Early complications were documented 345 times and were followed by reoperation in 84 cases, or 7.4% of the total. Delayed stomal function was noted in 63 cases and required reoperation in 14. It was most common after Roux anastomoses and required operative intervention most commonly after gastric resection, Billroth I (GRBI). Delay was three times as common when vagotomy (V) was added to GR. Early postoperative hemorrhage was a serious complication when it occurred after operations for acute perforations or massive hemorrhage. The incidence was 3.7% after suture of a perforation; after operations for acute massive hemorrhage, it was 4.3% after pyloroplasty and vagotomy, with or without arterial ligation [PV(L)], and 0.3% after GR, with or without arterial ligation [GR(L)]. Late complications led to reoperation in 66 cases (6.2%). The most important were recurrent ulceration and alkaline gastritis. Recurrence rates after a minimum follow-up of 5 years (based on survivors of initial procedures and a second operation, both in the MGH) were 20.5% after suture of a perforation, 6.2% after PV, 2.3% after GRBII, and 0.4% after GRVBII. These figures are lower than expected; incomplete follow-up and improved medical care are factors.(ABSTRACT TRUNCATED AT 400 WORDS)

Role of transcatheter arterial embolization for massivebleeding from gastroduodenal ulcers

“…Thus, patients with impaired coagulation are three times more likely to rebleed after initially successful embolization and 10 times more likely to die as a result of bleeding, compared to those with normal coagulation [2,12] . Rescue surgery after a failed embolization attempt has a very high mortality rate that exceeds even the 50% rate associated with emergent surgery [31,32] . In other series, underlying medical problems such as cirrhosis and malignancy, had major impacts on the mortality rate.…”

APACHE II Scoring in Surgical Upper Gastrointestinal Emergencies

“…While some authors [1,2] advocate the use of truncal vagotomy and antrectomy (TV+A) for a bleeding duodenal ulcer, others [3] claim that truncal vagotomy and a drain age (TV+D) procedure is safer. The same argument involves the treatment of bleeding gastric ulcers.…”

Parietal Cell Vagotomy versus Vagotomy‐antrectomy: Ulcer Surgery in the Modern Era

“…The patient who suffers from dumping, diarrhea, or alkaline reflux cannot usually be treated effectively and is a persistent problem in the clinic and in the minds of the entire gastroenterologic team. Avoidance of these complications was the major impetus for the development of alternative operations that do not have the same potential for causing these problems [8,9,11,12]. A new approach, a primary prevention of postoperative problems, became the focus of Harkin's pupil, Nyhus, who introduced the PGV into clinical practice in the United States when he came to the University of Illinois at Chicago [8].…”

“…Because operations for duodenal ulcer will continue to be needed in some patients, and because the results after HSV are superior to TV-A in most patients, it is appropriate to reiterate and review the status of this procedure [11,24,25]. This is particularly evident in view of the increasing popularity of laparoscopic techniques for duodenal ulcer.…”